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<br />Organization license APPlication. LG200A
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<br />The information req ested rm ( nd
<br />any attachments) Will be Used by the GambUng
<br />Control Boam (Board) to determine yourquaU_
<br />fications 10 be involveeI In lawful gambling ac-
<br />tivities in Minnesota, and to assist the Board in
<br />conducting a background investigation Of You.
<br />You have Ihe right to refuse 10 SUPPly the in-
<br />formallon requested; however, if you refuse
<br />to SUPPly this Information, the Board may nOI
<br />be abie to determine Your quaUfications and,
<br />as a consequence, may refuse to issue you a
<br />lioense./fyOu sllpp/Ylhe information teqUSstect,
<br />the Board Will be able to Process YOUr appUca_
<br />lion.
<br />
<br />This form may require the diSclOsure Of Your
<br />SOciai Security number. If so, Your SOCial
<br />Security number Will be USed to determine yOur
<br />
<br /> Gambling Manager
<br /> Name of Your organization's gambUng manager Address City Slate/Zlp
<br /> ^-latcJ.le }v(QC~ 7/2../ Show 00Ln UnO l~ N/..j 550 14
<br /> O".nl''''on Inoom. 'nd A'U"d.. ''''''h '''m"",,I'h~. . '~'h"Y)
<br /> '" o.."..,~ m" '" ~~ .... "..,,~ "W(" "_,. """",, ,,"... "_ _ ,,", '.."....,
<br /> raises funds.
<br /> ~ (u/lpCf/~ .BCrjOdiCJ.~eol)s.
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<br /> " """',,,,, .,. -. "" .,.... · "- ."...."~. WhO( h -. ,,-, """ """ .... -m"", _
<br /> gambling? _ ) () _%
<br /> AttaChments and Information ReqUired
<br /> - Organization Officers Affidavit. LG200B - CompenSation SChedule, LG205
<br /> o CEO and treasurer must eaCh COmplete 0 Use to report all wages Paid to emplOYees
<br /> - Proof of NonprOfit Status involved in the COndUct of laWful gambling.
<br /> - Organization BYlaws o If no wages paid, return the LG205 Signed by
<br /> Membership LiSf, signed by CEO and notarized the CEO stating "No compenSation Paid."
<br /> - - Registration of Paid Gambling EmplOYees,
<br /> Intemal Controls, LG201
<br /> - Allach a flow chart ShOWing the structure of Your LG209
<br /> organiZation and a separate WHllen eXPlanation of
<br /> administrative duties.
<br />ACknoWledgment
<br />I declare thaI:
<br />0 I have read this application and all infOrmation sUbmilled 0 Any Changes in apPUcation infOrmation Will be SUbmit.
<br /> to the Board. ted to the Board and local govemment Wifhin ten dayS
<br />0 All information is true, aCCurate, and COmplete. Of/he change.
<br />0 All other required information has been fully diSclosed. 0 A termination plan Will be sUbm/lled to the Board Within
<br />0 I am ihe chief executive Officer of the organization. 30 days of termination of OUr gambling operation.
<br />0 f assume full responSibility for the fair and laWful opera. 0 I certify that the gambling manager Is bOnded and
<br /> tion of all actiVities to be COnducted. licensed as reqUired per Minnesota statutes.
<br />0 I Will familiarize mYself With the laws of Minnesota 0 Failure to prOVide required Information or ProViding false
<br /> goVeming laWful gambling and rules of the Board, and or miSleading information may result in the denial Or
<br /> agree, if licensed, to abide by those laws and rules, revocation Of the license.
<br /> inClUding amendments to them. .' I
<br />"- "'''''' "'''W~ -"(i/Mc-~ 'i/ "./'/Hi~ - Date_~/-2::.~
<br /> Mail To: Gambling ContrOl Board QUestions? Call the licensing SeCtion of the GambUng Control
<br /> Suite 300 South 80am at 651-639-4000. If you use a ny, you can call the 80am
<br /> 1711 W. COunty Road 8 by Using the Minnesota Relay Service at 1-800-627_3529 afl(f
<br /> ask to place a call 10 651-639-4000. This form Will be made
<br /> RosevlI/e, MN 55113 available in altematl\le format (i.e. large Print Braille) upon request
<br /> u on this fa a
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<br />name and address Which Will remain PUblic.
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